Visual Electrodiagnostic Clinic

                                                                          Eyetech Southside                                                             

            22 Sanders St, Upper Mt Gravatt Qld 4122               

Phone: 07 3420 4899 FAX 07 3349 7260                     

                                                                                                                                                                                   
Patient Name: .............................................................................Date of Birth: ...................................

Patient Phone: .........................................................................................................................................

Clinical Details: Best Corrected VA Right ……………….… VA Left ……………….………....

Visual Fields: ..........................................................................................................................................

History & Examination: .........................................................................................................................................

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....................................................................................................................................................................................

Provisional Diagnosis:............................................................................

Tests Requested:             Electroretinogram (ERG)              [   ]

                                          Electrooculogram (EOG)                [   ]

                                                                                    Pattern ERG (PERG)                        [   ]                    

                                        Multifocal ERG (MFERG)                 [   ]

                                        Visually Evoked Potential (VEP)     [   ]            

                                         Visual Acuity* (AVEP)                     [   ]

                                         Colour vision (100Hue)                    [   ]

                                          Clinical Review                                [   ]

                                        

** When possible all patients will be reviewed at the time of the tests

Name of Referrer: .......................................................Provider No: .............................................
 

Email Address for Report: ....................................................................................................................

Signature: …………………………….……… DATE: ................Provider Number:..................................

Date of next appointment with Referrer: .............................................          


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